Provider Demographics
NPI:1902160674
Name:NELSON, PENNY LOUISE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:LOUISE
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 N JACKSON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1607
Mailing Address - Country:US
Mailing Address - Phone:408-926-5300
Mailing Address - Fax:408-926-5395
Practice Address - Street 1:280 N JACKSON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1607
Practice Address - Country:US
Practice Address - Phone:408-926-5300
Practice Address - Fax:408-926-5395
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13009363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant